Values-Related Barriers Promoting Strategies for Sexual Health Assessment in Nursing Practice

I. A. A. Bdair, R. E. ConsTantino 482 not a priority [33] . In China, nurses reported that nurses’ shortage and lack of resources are significant barriers to address patients’ sexual health [55] . Fur- thermore, lack of support from the institutions [56] , lack of privacy [57] , work overload and a sense that addressing sexual health is non-nursing job [29] are cited as organizational barriers. Academic nursing curricula in Jordan often ignore discussing of sexual health issues for nursing students. Despite that, several studies reported that addressing sexual health issues during undergraduate education is vital to increase nurses’ knowledge [33] [58] .

4.5. Values-Related Barriers

Finally, culture, society, and religion are external barriers that are related to val- ues of persons or community preventing assessment of sexual health with pa- tients during their hospitalization. Many cultures including Arab Islamic culture considering sexual related topics are sensitive. Goossens et al examined the im- pact of culture in five Europe countries and found that nurses’ beliefs and atti- tudes about sexual health are influenced by both culture and country [30] . In some cultures, there is a common belief that sexual health is not a matter for older adults or those who with chronic conditions [59] . Turkish nursing stu- dents’ did not offer sexual health assessment and education to patients due to effects of cultural and religious beliefs [60] . In the Turkish culture, open com- munications about sexual matters between different sexes is prohibited, then preventing nurses from sexual health assessment [61] . Societal restrictions can interfere with providing sexual health care [29] . Pu- rabuli, Azizzade and Alizadeh found that most nurses in Iran 96 highlight the necessity for nurse educators to be same sex as the patient [40] . Social inter- pretation of sexual issues is another barrier, for example, sex means pleasure and enjoyment and it is not logical to address it during illness. Based on this inter- pretation, Chinese nurses pay more attention to physical health condition rather than sexual concerns [55] . In summary, to gain more depth insight, all possible barriers to sexual health assessment in nursing practice based on reviewed studies are outlined below in Table 2 .

4.6. Promoting Strategies for Sexual Health Assessment in Nursing Practice

As sexual health-related needs are sensitive issues and often challenging task for nurses. Special considerations are required to help nurses conducting patients’ sexual health assessment in clinical practice. In attempts to overcome barriers, we suggest a multidisplinary team to develop standardized guidelines to sexual health assessment. Strategies to facilitate sexual health assessment are outlined below. First: Integrate sexual health assessment topics in nursing curriculum during undergraduate studies. Jaarsma et al . found that nurses have knowledge deficit I. A. A. Bdair, R. E. ConsTantino 483 Table 2. Barriers to sexual health assessment in clinical nursing practice. Category Barriers Nurses related barriers Lack enough time to address patients’ sexual health Lack of knowledge about sexual health Lack of training about sexual health Nursing shortage and heavy workload Lack of educational materials about sexual health Sexual health assessment is not nurses’ responsibility physician The patient is too ill and not ready for sexual health assessment Nurses feel uncomfortable with sexual health assessment Presence of a third party with patient during hospital stay Afraid to offend the patient or afraid from offend response No connection with the patient Gender difference male-female between nurses and patients Focus on physical illness rather than sexual health Sex is a private matter Patients do not ask about sexual health Misunderstanding of nurse who ask about sexual health maters Social interpretation Nurses own beliefs, values and attitudes about sexual health Patient related barriers Sexuality is not an issue for some patients not interested The patient is too ill and not ready to receive sexual health assessment Presence of a third party with patient during hospital stay Patients do not ask about sexual health Old age of the patient Sexual health assessment is not nurses’ responsibility physician Gender difference male-female between nurses and patients Misunderstanding of patient who ask about sexual health maters Social interpretation Organizational and academic related barriers Lack of privacy rooms for sexual health assessment Lack of educational materials about sexual health Lack of motivation from health care institutions low priority Lack of sexual health assessment section from nursing assessment sheet Lack of organizational policies about sexual health assessment Nursing shortage and heavy workload Lack sexual health education in undergraduate studies Value related barriers Cultural or religious reasons Social restrains prevent talks about sexual topics Language or ethnicity reasons Sex is a private matter Age difference between nurse and patient old patient and young nurse Gender difference male-female between nurses and patients Social interpretation of sex means pleasure and enjoyment Nurses own beliefs, values and attitudes about sexual health Means that barrier is related to two or more categories. I. A. A. Bdair, R. E. ConsTantino 484 and lack of confidence to talk about sexual matters [24] . Well-prepared nurses in term of knowledge and skills make them more confident in providing sexual health assessment and information. Second: Conduct training sessions and workshops on sexual health assess- ment for nurses in clinical setting sexual health competency. Training pro- grams about sexual health improve nurses’ comfort and attitude toward bringing sexual health assessment into practice [35] [36] . Clinical training workshops with simulation role-play case scenarios by nurse specialist in sexuality matters is highly recommended to help nurses addressing patients’ sexual health [24] . Third: Teach effective communication skills to nurses and build rapport and therapeutic relationship between nurse and patients to make nurses more able to translate their acquired sexual knowledge into practice [55] . The close relation- ship between nurses and patients gives both a great chance to discuss sexual con- cerns [62] . Nurses could use their art to address patients’ sexual health in a way that fit with patients’ values, beliefs, culture and religion. As many cultures view sexual matters as secret and private, nurses need to take cultural perceptions in the process of sexual health assessment [37] . To achieve a successful addressing of sensitive information, Waltz, Strickland and Lenz recommended ensuring pri- vacy and confidentiality of patients’ responses; seeking only relevant data start- ing from less to more sensitive and allowing more time for participants to express their needs [63] . Fourth: Use written educational material such as brochures and leaflets that are developed by experts about sexual health. These materials play an important role in improving patients’ knowledge and encourage patients to express their sexual health concerns [19] . Fifth: Select appropriate time is an important factor for effective assessment and teaching of patients’ sexual health. For example, nurses viewed that time is not suitable for discussing sexual concerns as patients are ill and they may have anxiety and fear due to their conditions [59] . As existence of third party is a bar- rier, before or after visiting hours is more appropriate for both nurse and patient to address sexual health needs. Discharge period is a suitable time where patients become stable and ready for assessment and to receive information. Three quar- ters of nurses recommended that the best time to assess patients’ sexual health is during their follow-up visits or during medications review [5] . Sixth: Create, adopt and implement sexual health policies and procedures for sexual health assessment in clinical settings to facilitate nurses’ roles in conduct- ing this important nursing task [34] . For example, integrating sexual assessment as a part to the nurses’ charts enable nurses to address the sexual health during history taking and discharge planing. Annon developed the PLISSIT model as a tool to facilitate the assessment and treatment of sexual related problems. PLISSIT letters are abbreviations for sequent interventions where P means Permission; LI means Limited Information; SS mean Specific Suggestions and IT means Inten- sive Therapy [64] . The PLISSIT model is a framework that helps nurses to con- duct sexual health assessment [42] . I. A. A. Bdair, R. E. ConsTantino 485 Seventh: Invite partners during sexual health assessment and counseling. Part- ners may complain of distress and anxiety that may affect patient’s sexual health [65] . Partners play significant roles in patient support and facilitating successful resuming of sexual activities. Eighth: Break down external barriers, Media can play a vital role in discussing the sexual health and related concerns publicly. Nurses can present a television shows about sexual health and instructions for patients and their partners. Ninth: Nurses need to understand patients and partners’ sexual health expe- riences and needs for sexual health information, nurses’ knowledge, attitudes, beliefs, barriers and best teaching methods. Conducting more research in sexual health nursing field is recommended to improve sexual health assessment [44] . Tenth: Create an appropriate work environment through establishing specia- lized rooms in health institutions to help both nurses and patients to address sexual health related issues in a more comfortable manner [37] .

5. Discussion